Sandbox/AL: Difference between revisions
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===Cardiac Chest Pain=== | ===Cardiac Chest Pain=== | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | A01 | | | | | | A01= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Does the EKG has ST elevation?''' </div>}} | {{familytree | | | | | | | | A01 | | | | | | A01= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Does the EKG has ST elevation?''' </div>}} | ||
{{familytree | | | |,|-|-|^|-|-|.| | | |}} | {{familytree | | | |,|-|-|-|-|^|-|-|-|-|.| | | |}} | ||
{{familytree | | | B01 | | | | B02 | | | | B01= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | B02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>}} | {{familytree | | | B01 | | | | | | | | B02 | | | | B01= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | B02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>}} | ||
{{familytree | | | |!| | | | | |!| | | | | |}} | {{familytree | | | |!| | | | | | | | | |!| | | | | |}} | ||
{{familytree | | | C01 | | | | C02 | | | | |C01=<div style="float: left; text-align: center; width: 14em; padding:1em;">'''Is the ST elevation specific to an anatomic area'''<br> ❑ V1-V2 (Septal) <br> ❑ V3-V4 (Anterior) <br> ❑ V5-V6 (Apical) <br> ❑ I, aVL (Lateral) <br> ❑ II, III, aVF (Inferior) <br></div> | C02= <div style="float: left; text-align: center; width: 14em; padding:1em;">''' | {{familytree | | | C01 | | | | | | | | C02 | | | | |C01=<div style="float: left; text-align: center; width: 14em; padding:1em;">'''Is the ST elevation specific to an anatomic area'''<br> ❑ V1-V2 (Septal) <br> ❑ V3-V4 (Anterior) <br> ❑ V5-V6 (Apical) <br> ❑ I, aVL (Lateral) <br> ❑ II, III, aVF (Inferior) <br></div> | C02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''Does the [[TTE]] shows valve or aortic abnormalities?''' </div> }} | ||
{{familytree | |,|-|^|-|.| | | | | {{familytree | |,|-|^|-|.| | | | | |,|-|^|-|.| | |}} | ||
{{familytree | D01 | | D02 | | | | |D01=<div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | D02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>}} | {{familytree | D01 | | D02 | | | | D03 | | D04 | | |D01=<div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | D02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>| D03=<div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | D04= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>}} | ||
{{familytree | |!| | | |!| | | | | | }} | {{familytree | |!| | | |!| | | | | |!| | | |!|| |}} | ||
{{familytree | E01 | | E02 | | | | |E01=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Consider the following:'''<br> | {{familytree | E01 | | E02 | | | | E03 | | E04 | |E01=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Consider the following:'''<br> | ||
'''[[STEMI]]''' <br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ CK-MB and Troponin elevation <br> ❑ PR depression is absent <br> [[STEMI resident survival guide|Click here for detailed management]]<br><br> | '''[[STEMI]]''' <br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ CK-MB and Troponin elevation <br> ❑ PR depression is absent <br> [[STEMI resident survival guide|Click here for detailed management]]<br><br> | ||
'''[[LBBB]]''' <br> ❑ EKG evidence of LBBB | '''[[LBBB]]''' <br> ❑ EKG evidence of LBBB | ||
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: ❑ QS or rS in V1 | : ❑ QS or rS in V1 | ||
: ❑ Monophasic R in I, aVL and V6 | : ❑ Monophasic R in I, aVL and V6 | ||
❑ Chest pain with same characteristic as STEMI <br> [[STEMI resident survival guide|Click here for detailed management]]<br><br> </div> | E02= <div style="float: left; text-align: left; width: 14em; padding:1em;"> '''[[Pericarditis]]''' <br> ❑ Diffuse, non-specific ST elevation <br> ❑ PR depression is present <br> ❑ PR elevation in lead aVR is present <br> ❑ <br> ❑ <br> [[Pericarditis resident survival guide|Click here for detailed management]]<br><br> </div>}} | ❑ Chest pain with same characteristic as STEMI <br> [[STEMI resident survival guide|Click here for detailed management]]<br><br> </div> | E02= <div style="float: left; text-align: left; width: 14em; padding:1em;"> '''[[Pericarditis]]''' <br> ❑ Diffuse, non-specific ST elevation <br> ❑ PR depression is present <br> ❑ PR elevation in lead aVR is present <br> ❑ <br> ❑ <br> [[Pericarditis resident survival guide|Click here for detailed management]]<br><br> </div>| E03= |E04=}} | ||
{{familytree/end}} | {{familytree/end}} | ||
===Non-Cardiac Chest Pain=== | ===Non-Cardiac Chest Pain=== |
Revision as of 19:38, 25 April 2014
Overview
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
Boxes in the red signify that an urgent management is needed.
Abbreviations:
Identify cardinal findings that increase the pretest probability of life-threatening chest pain ❑ Sudden onset ❑ ❑ ❑ Related physical exertion | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Does the patient have any of the findings that require urgent management? ❑ Tachycardia ❑ Hypotension ❑ Altered mental status ❑ Severe dyspnea ❑ Oliguria ❑ Cold extremities | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Initiate resuscitation measures: ❑ Secure airway ❑ Administer oxygen if SatO2 ≤95% ❑ Secure wide bore IV access ❑ Perform ECG monitor ❑ Monitor vitals continuously ❑ Immediately order an ECG | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
ECG findings | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Presence of ST elevation | Absence of ST elevation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Does the patient have both of the following: ❑ There is ST elevation in a limited number of leads that fits the anatomic distribution of a coronary artery (examples would include but are not limited to leads 2,3,F, or Leads v1-v4) | ❑ Evidence of LBBB | Does the patient have any of the following: ❑ There is ST elevation in multiple leads that does not follow an anatomic distribution of coronary arteries (ST elevation is diffuse) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
STEMI | LBBB | Pericarditis | Angina | Aortic dissection | Pulmonary embolism | Tension pneumothorax | Esophageal rupture | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Look for supportive signs and symptoms: ❑ The pain is described as a heaviness or crushing sensation | Look for supportive signs and symptoms: ❑ The pain is described as a heaviness or crushing sensation | Look for supportive signs and symptoms: ❑ Pleuritic pain | Look for supportive signs and symptoms: ❑ | Look for supportive signs and symptoms: ❑ Back pain
| Look for supportive signs and symptoms: ❑ Shortness of breath | Look for supportive signs and symptoms: ❑ Sudden shortness of breath | Look for supportive signs and symptoms: ❑ Vomiting | {{{ }}} | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Click here for the detailed management | Click here for the detailed management | Click here for the detailed management | Angina | Click here for the detailed management | Click here for the detailed management | Click here for the detailed management | Click here for the detailed management | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Complete Diagnostic Approach
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.
Abbreviations:
Characterize the chest pain ❑ Onset (sudden or gradual) | |||||||||||||||||||||||||||||||||||||||||
Characterize the symptoms Non-specific symptoms
❑ ❑ Colicky (suggestive of cholelithiasis) ❑ Epigastric pain ❑ ❑ ❑ ❑ ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
Inquire about past medical history: ❑ Previous episodes
❑ Recent medical procedures
❑ Pulmonary disease
❑ Neurological diseases | |||||||||||||||||||||||||||||||||||||||||
Identify possible triggers: ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
Examine the patient:
Vitals Cardiovascular examination Abdominal examination Neurological examination | |||||||||||||||||||||||||||||||||||||||||
Does the chest pain has any of the following findings suggestive of cardiac etiology? ❑ ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||||||||||||
Does the EKG has ST elevation? | Determine the non-cardiac etiology based on the physical examination and tests findings | ||||||||||||||||||||||||||||||||||||||||
YES | NO | Pulmonary | Gastrointestinal | Other | |||||||||||||||||||||||||||||||||||||
Consider the following: STEMI
❑ Chest pain with same characteristic as STEMI ❑ Diffuse, non-specific ST elevation ❑ PR depression is present ❑ PR elevation in lead aVR is present ❑ ❑ Click here for detailed management | Consider the following: Aortic stenosis ❑ ❑ ❑ Click here for detailed management | Consider the following: Pulmonary embolism ❑ ❑ ❑ Click here for detailed management | Consider the following: GERD ❑ ❑ ❑ Click here for detailed management | Consider the following: Musculoskeletal pain ❑ ❑ ❑ Click here for detailed management | |||||||||||||||||||||||||||||||||||||
Cardiac Chest Pain
Does the EKG has ST elevation? | |||||||||||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||||||||||
Is the ST elevation specific to an anatomic area ❑ V1-V2 (Septal) ❑ V3-V4 (Anterior) ❑ V5-V6 (Apical) ❑ I, aVL (Lateral) ❑ II, III, aVF (Inferior) | Does the TTE shows valve or aortic abnormalities? | ||||||||||||||||||||||||||||||||||||||
YES | NO | YES | NO | ||||||||||||||||||||||||||||||||||||
Consider the following: STEMI
Click here for detailed management | Pericarditis ❑ Diffuse, non-specific ST elevation ❑ PR depression is present ❑ PR elevation in lead aVR is present ❑ ❑ Click here for detailed management | ||||||||||||||||||||||||||||||||||||||
Non-Cardiac Chest Pain
Treatment
Shown below is an algorithm summarizing the therapeutic approach to chest pain based on the
Abbreviations: